REGIONAL ANESTHESIA Anesthesia Care Teams and Block Areas NAPAN Conference Sue Belo MD PhD FRCPC May 23rd, 2009.

REGIONAL ANESTHESIAAnesthesia Care Teams and Block Areas

NAPAN ConferenceSue Belo MD PhD FRCPC

May 23rd, 2009

HOLLAND CENTRE

The Holland Centre

AMALGAMATION 1998

Orthopedic and Arthritic Hospital

SunnybrookHospital

Orthopedic and Arthritic InstituteSWCHCS

Holland Centre 2005

Resources

• 4 Operating Rooms• 5 bay Post Anesthesia Care Unit• 10 bay Same Day Admission Area• 5 Anesthetists (OR and Pre-assessment)• 50 Acute Care Beds• 20 Short term Rehab Beds

2004

• 3200 cases per year• 1500 total joint arthroplasties• 100% under General Anesthesia• Limited use of femoral nerve blocks• Post-op nurse-managed morphine PCA

2004

• Average length of stay 7 days• In-patient rehab 10 days• 20% to long term rehab 16 days

2004

• Average 16/20 lists per month ran overtime• Average overtime 30 hours/month• Average 18 cancellations/month

• How can patient care be improved at the Holland Centre?

• Wait Time strategy 2004

• Holland Centre of Excellence Aug 2005

• Anesthesia and Nursing shortages

Regional Anesthesia

• 4-fold reduction in mortality with regional compared to GA (Shamrock et al 1995)

• decreased DVT/PE; decreased blood loss and transfusion rate (Mauermann et al 2006)

• better pain control and decreased opioid use (Salinas et al 2006)

• improved surgical outcomes (Peters et al 2006)

VISION

Convert the Holland Centre to Regional Anesthesia

Regional Anesthesia at the Holland Centre

• better patient care• decrease overtime and cancellations

through increased efficiency• ability to increase volume of cases• increase nursing satisfaction• increase recruitment and retention

• prolonged operating room time• decreased efficiency• unpredictable success rate• inferior surgical conditions• unacceptable to patients

CHANGE!!

Anesthesia Concerns

•Regional Anesthesia requires time•Regional Anesthesia requires expertise•Regional Anesthesia requires co-operation•Regional Anesthesia requires a team effort

Investment for Improvement

Administration Concerns

$$$$$$

Anesthesia Care Team Model

• Create a separate but adjacent “Block Area” (4 bays)

• “Block RNs” to staff area (2)– check patients, prepare equipment, monitor patients

• Anesthesia Assistants (2) – monitor stable patients under regional anesthesia in OR while

anesthetist performs regional/blocks for next patient

• Anesthesiologists (4)– each anesthesiologist does own blocks in the Block Area

Patient Flow

OR

Same Day Admission

Block Area

PACU

2007

Surgeon Education

• Approached surgeons individually and as a group

• Provided relevant literature (including surgical literature)

• Presented rounds

Nursing Education

• Involved Pre-Assessment Clinic nursing staff, ward nurses, OR nurses

• Provided with literature, in-services• Invited to Block Area and PACU

Allied Health Professionals

• educational sessions for Physiotherapy• feedback from Physiotherapy on issues in

regards to rehab• revision of practice and protocols to address

concerns with hypotension, prolonged motor block, etc.

• consultation with Pharmacy re pre-op medications, pre-printed orders

Patient education

• by anesthetist at pre-op visit• patient information pamphlets• DVD video sent home with patient• Web-site

Post-operatively

• established an Acute Pain Service under the direction of Nurse Practitioner and a dedicated anesthesiologist (Nov 2005)

• developed best practices for post-op pain management (epidural analgesia, PCEA, oral analgesia protocols for THR, multi-modal analgesia regimens)

• Developed protocols and standardization for selected procedures initially and introduced new procedures slowly

– Spinal Anesthesia for THR and TKR– Femoral Nerve Blocks for TKR– Sciatic Nerve Blocks for TKR– Combined spinal epidural anesthesia for bilateral TKR– Peripheral nerve block catheters

2007

• 2100 total joint arthroplasties• Neuraxial anesthesia in 90% • Peripheral nerve blocks used in 90% of TKA• Peripheral nerve block catheters for continuous

infusions

OR Time

KneesHips

Type

125

100

75

50

25

0

Mea

n S

urg

ical

Tim

e

Error bars: +/- 1 SD

2007

2004

Year

17% decrease in time for patient-in to patient-out from 2004 to 2007 in total knee arthroplasties18.6% decrease in time required from patient-in to patient-out for total hip arthroplasties

OR Overtime(* cancellations)

PACU Length of Stay

• Average LOS 4.8 days• 67% discharged home (day 5) • 24% short term in-pt rehab- 5 days (day 3) • 9% longer in-pt rehab

Anesthesiologist’s Perspective

• Changes in anesthetic practice facilitated improved efficiency and “fast-tracking”

• Improvement in global peri-operative care• No incremental risk for patients• Improved outcomes • Benefits for patients, physicians, nurses,

allied health care practitioners• No additional Anesthesia resources

required

PACU Discharge CriteriaModifications for Spinal Anesthesia

• sensory block level at a minimum of T8• recession of sensory block by at least one

dermatome level• any patient admitted to PACU with a sensory

block at T10 or below and some movement of the lower extremities may be discharged from PACU

64.6

40.9

010203040506070

Time (minutes)

2007 2009

Year

PACU readiness for discharge

The Future

Improved patient care• Continuous catheters• Patient controlled oral analgesia• Expanded ultrasound applications• Optimization of drugs and dosages• Best Practice guidelines• Expansion of Anesthesia Care Team model

• Retainment and Recruitment(Anesthesiologists, Block RNs, Anesthesia Assistants)

• Documenting improved outcomes• Continuous improvement• Expansion of program to Sunnybrook site• Maintaining expertise at 2 sites

THANK YOU